Provider Demographics
NPI:1639613771
Name:DOWNTOWN DENTAL CT PC
Entity Type:Organization
Organization Name:DOWNTOWN DENTAL CT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMINOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-203-1611
Mailing Address - Street 1:205 MAIN ST
Mailing Address - Street 2:# 4
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851
Mailing Address - Country:US
Mailing Address - Phone:203-857-1854
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:# 4
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-3530
Practice Address - Country:US
Practice Address - Phone:203-857-1854
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0108591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042136Medicaid